Cardiogenic shock with non-ST-segment elevation myocardial infarction: a report from the SHOCK Trial Registry. SHould
A K Jacobs1, J K French, J Col
1Department of Medicine, Boston Medical Center, Massachusetts 02118, USA. alice.jacobs@bmc.org
Insights
Patients with cardiogenic shock (CS) and non-ST-segment elevation myocardial infarction (MI) have a higher-risk profile but similar mortality to those with ST-elevation MI. Earlier intervention for recurrent ischemia and circumflex artery occlusion is recommended.
Area of Science:
- Cardiology
- Acute Myocardial Infarction
- Cardiogenic Shock
Background:
- Cardiogenic shock (CS) complicating non-ST-segment elevation myocardial infarction (MI) represents a high-risk group with unknown optimal therapy.
- Patients may present with ST depression or normal/nonspecific ECG findings.
Purpose of the Study:
- To determine the outcomes of patients experiencing cardiogenic shock (CS) secondary to non-ST-segment elevation acute myocardial infarction (MI).
Main Methods:
- Analysis of 881 patients with CS due to left ventricular dysfunction from the SHOCK Trial Registry.
- Comparison of characteristics and outcomes between non-ST-segment elevation MI (n=152) and ST-elevation MI (n=729) groups.
Main Results:
- Non-ST-segment elevation MI patients were older with more comorbidities but similar in-hospital LV ejection fractions.
- Despite higher rates of recurrent ischemia, non-ST-segment elevation MI patients underwent less angiography and revascularization.
- In-hospital mortality was similar between the non-ST-segment elevation MI (62.5%) and ST-elevation MI (60.4%) groups.
Conclusions:
- Patients with CS and non-ST-segment elevation MI exhibit a higher-risk profile but comparable in-hospital mortality to those with ST-elevation MI.
- Increased recurrent ischemia and reduced angiography in non-ST-segment elevation MI suggest opportunities for earlier intervention.
- Consider early reperfusion therapy for circumflex artery occlusion in non-ST-segment elevation MI-induced CS.
Objectives:
We sought to determine the outcomes of patients with cardiogenic shock (CS) complicating non-ST-segment elevation acute myocardial infarction (MI).
Background:
Such patients represent a high-risk (ST-segment depression) or low-risk (normal or nonspecific electrocardiographic findings) group for whom optimal therapy, particularly in the setting of shock, is unknown.
Methods:
We assessed characteristics and outcomes of 881 patients with CS due to predominant left ventricular (LV) dysfunction in the SHOCK Trial Registry.
Results:
Patients with non-ST-segment elevation MI (n = 152) were significantly older and had significantly more prior MI, heart failure, azotemia, bypass surgery, and peripheral vascular disease than patients with ST-elevation MI (n = 729). On average, the groups had similar in-hospital LV ejection fractions (approximately 30%), but patients with non-ST-elevation MI had a lower highest creatine kinase and were more likely to have triple-vessel disease. Among patients selected for coronary angiography, the left circumflex artery was the culprit vessel in 34.6% of non-ST-elevation versus 13.4% of ST-elevation MI patients (p = 0.001). Despite having more recurrent ischemia (25.7% vs. 17.4%, p = 0.058), non-ST-elevation patients underwent angiography less often (52.6% vs. 64.1%, p = 0.010). The proportion undergoing revascularization was similar (36.8% for non-ST-elevation vs. 41.9% ST-elevation MI, p = 0.277). In-hospital mortality also was similar in the two groups (62.5% for non-ST-elevation vs. 60.4% ST-elevation MI). After adjustment, ST-segment elevation MI did not independently predict in-hospital mortality (odds ratio, 1.30; 95% confidence interval, 0.83 to 2.02; p = 0.252).
Conclusions:
Patients with CS and non-ST-segment elevation MI have a higher-risk profile than shock patients with ST-segment elevation, but similar in-hospital mortality. More recurrent ischemia and less angiography represent opportunities for earlier intervention, and early reperfusion therapy for circumflex artery occlusion should be considered when non-ST-elevation MI causes CS.
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